A third reported impact of non-managed care health market change has been the erosion of disease reporting efforts. Several states reported that large, national reference laboratories with regional testing centers pose a threat to the national disease surveillance effort. Michigan's PHL director noted that private, out-of-state laboratories are often unfamiliar with the disease reporting laws and regulations pertaining to the state from which the specimen originates. As a result, there are instances in which bacterial/viral isolates are not being submitted to state laboratories, thereby jeopardizing public health surveillance mechanisms. In Arizona, some physicians use private laboratories such as LabCorp and SmithKline Beecham for newborn PKU testing. These private laboratories send the tests out of state for testing, and the infants are lost to follow up by the state health agency. In other cases, Arizona's PHL director reports that some out-of-state commercial laboratories decline to report cases of reportable diseases altogether.